2.0 Analysis 2.1 Sequence of Events Leading to the Grounding Due to a lack of eyewitness testimonies, it was not possible to either determine the precise sequence of events leading to the grounding or establish if the operator's medical condition contributed to the grounding. However, there are compelling factors that could account for the operator's performance. 2.2 Factors Affecting Grounding 2.2.1 Set, Drift and Load Condition Neither the load condition nor the prevailing weather conditions are considered to have adversely affected the safe navigation of the vessel. The southern entrance to Grand Passage is subjected to funnelling effect4 and the flood tide was just beginning to build; therefore, the effect of the wind would have been to retard the progress of the vessel. 2.2.2 Navigational Approach and Buoy Position Because local fishing vessels, including the STUMP JUMPER, often work close inshore, close to Dartmouth Point Ledge, they do not usually refer to buoy HA2. Soundings cannot provide advance warning of the steep-to ledge. Therefore, extreme caution must be exercised while navigating close offshore in its vicinity. The buoy was not in position, but it had not been used for reference. 2.2.3 Deployment of Personnel Because the vessel was navigated close to shore in the vicinity of the Dartmouth Point Ledge, the operator had to be alert and maintain situational awareness. However, the operator was not aware of the vessel's position at the time of the grounding. This might indicate that he had not been monitoring the radar closely. One of the deck-hands was knowledgeable of navigational practices and procedures but the operator did not ask him for assistance during harbour entry, despite the operator's poor health and demanding work schedule. 2.3 Health of the Operator In this instance, ship motions, workload on deck, number of hours worked, environmental conditions such as temperature, noise, vibration, and food intake, among others, affected the performance of the vessel's personnel. During the first two days of the lobster fishing season, the crew is subjected to a heavy workload and work days of more than 12 hours. On the day of the occurrence, the crew of four handled 375 traps, each weighing in excess of 40 kg, in some 11 hours, which represents an average of one trap every two minutes. This does not take into account the time elapsed between hauling each string of traps and travelling between the strings. Small vessels such as the STUMP JUMPER invariably pitch and roll even in the most moderate sea conditions, which increases the physical workload and stress on the crew. The operator's performance could have been further impaired by fatigue resulting from minimal rest periods during 12-hour workdays, especially if his diabetic condition was aggravated by his not taking prescribed medication or adhering to his diet. As the examination of medical records revealed that the operator's blood sugar content was at times elevated, it would suggest that he did not always adhere to his prescribed diet and/or the medication schedule. However, in the absence of information pertaining to his food and medication intake for the period preceding the occurrence, the extent to which these factors affected his performance could not be determined. Some minutes after the grounding, the operator was seen lying on deck unable to help himself or to verbally respond to queries. This would suggest that the operator was seriously impaired. No autopsy or post-mortem testing was carried out to establish whether pre-existing medical factors had contributed to the operator's death. Nonetheless, given the obesity of the operator, the possible effects of altered blood sugar levels in conjunction with the long hours worked, the possibility that the operator sustained severe and eventually debilitating metabolic changes, a cardiovascular event, or even a stroke, cannot be ruled out. The operator was washed overboard within minutes of the grounding, was not wearing a PFD, could not swim and was in poor health; all of which contributed to his death. Thus, the operator's inability to stay afloat in conjunction with his poor health and possible loss of consciousness seriously compromised his survival. 2.4 Factors Affecting Search and Rescue Channel 16 is the designated international calling and distress frequency and channel 6 is a designated ship-to-ship frequency. CGRS Yarmouth is not provided with VHF R/T channel 6; therefore, no recording of SAR communication on that frequency was possible. The STUMP JUMPER communicated with fishing vessels involved in SAR operations on channel 6, but CGRS Yarmouth is not provided with that channel. Thus, it is not possible to precisely evaluate the efficiency of the SAR operations conducted by the fishing vessels and the impact of the role played by the WESTPORT. 2.4.1 Communication and Tasking of Search and Rescue Resources Examination of recorded CGRS transcripts revealed that the information requested was in accordance with the recognized international directives for transmitting distress messages and was necessary to elicit vital information not provided by the STUMP JUMPER. Although the messages transmitted by the STUMP JUMPER were not prefixed with Mayday or PAN, CGRS Yarmouth promptly apprised RCC Halifax and the WESTPORT of the situation. This resulted in the WESTPORT expeditiously arriving on scene some 11 minutes later. As the information from the distressed vessel was not complete and as the STUMP JUMPER unilaterally ceased communication on channel 16 and switched to channel 6 (to which the CGRS had no access), the CGRS was unable to directly monitor the situation. The CGRS, therefore, had to rely on information received from the WESTPORT. The need for a helicopter was established only after the WESTPORT arrived on scene and appraised the situation, at which time its services were requested. Nevertheless, the request was made quickly, some 19 minutes after the first communication between the distressed vessel and the CGRS. Because the operator was washed overboard shortly after the grounding and his survival was seriously compromised, even an earlier response from the helicopter consistent with daytime operation could not have altered the outcome of this occurrence. In this instance, although the aircraft was only required to be airborne in two hours, prompt action by the helicopter crew is depicted by the helicopter being airborne 42 minutes after it was tasked and arriving on scene in 1 hour 7 minutes. 2.4.2 Premature Abandonment - Assessment by Search and Rescue Technician The records show that there have been cases where premature abandonment of a stranded vessel in bad weather has resulted in loss of life, while the vessel remained intact and could have provided refuge. The crew member who allowed himself to be carried overboard in effect abandoned the vessel before the arrival of the other fishing vessels and was fortunate to have been sighted and rescued. An assessment of the situation by the SAR technicians on scene revealed that the personnel aboard the STUMP JUMPER could have been safely evacuated. By prematurely abandoning the vessel, the crew member subjected himself to additional risks. The operator did not abandon the vessel, but he was swept overboard by waves. 2.4.3 Effective Deployment of Shipboard Search and Rescue Personnel The coxswain of the WESTPORT is responsible for the effective deployment of the crew and is guided by the circumstances of each search. The crew of only three persons must be deployed to ensure that the coxswain can effectively monitor on-scene SAR activity and keep RCC abreast of the developing SAR situation. Because a sharp look-out is an essential component of a successful SAR operation, the coxswain deployed two look-outs forward despite the fact that he was experiencing difficulties in properly aiming the searchlight. The WESTPORT was subjected to rolling and pitching; therefore, the look-outs, stationed forward, had to hold on to the railings. A hands-free means of internal communication was not provided aboard the WESTPORT and difficulties were experienced in communications between the look-outs and the coxswain. Hence, as the searchlight controls were located within the wheel-house, difficulties were also experienced in properly aiming the searchlight. The positioning of the crew forward left the coxswain alone in the wheel-house to communicate and coordinate search activity and navigate in the midst of other fishing vessels while demands were placed on him to aim the searchlight. The positioning of one of the look-outs in the wheel- house would have relieved the coxswain from the additional burden of properly aiming the searchlight, leaving him to direct his attention to other important matters. 2.5 Perception of Search and Rescue Services and Response There was a lack of awareness by many fishermen and local Freeport residents with regard to the level of SAR services and response. The need to provide in-depth and accurate information on the vessel, position, nature of distress, life-saving equipment, which is essential to expeditiously effect a successful SAR operation, was not fully appreciated. Further, the majority of SAR occurrences the WESTPORT has responded to over the years, which comprised towing disabled fishing vessels into ports, were responded to promptly. As such, there was a general expectation that all SAR situations would be responded to quickly at any given time. The crew of the WESTPORT responded to the SAR situation in only five minutes, well within the 30-minute response period, and was on scene 11 minutes after being tasked. If the rigid-hull inflatable raft, which had to be manned by two persons, had been launched, the coxswain would have been left alone on the WESTPORT to conduct and coordinate SAR activity, safely operate the vessel, ensure the safety of the rigid-hull inflatable raft and its crew, and ensure the overall safety of the SAR operation. This, in conjunction with the prevalent weather conditions, precluded deployment of the rigid-hull inflatable raft. Its launching would have jeopardized the safety of the WESTPORT and other vessels participating in the SAR operation. However, the fishing vessels involved in the rescue effort expected the WESTPORT to take over and complete the SAR operation on arrival, enabling them to stand down. This led to the belief that the WESTPORT had merely stood by after arrival and let the fishing vessels complete the rescue. As the fishing vessels engaged in actively rescuing the survivors were close to each other, the WESTPORT considered it prudent to allow the two fishing vessels to continue with their rescue efforts, more so because the rigid-hull inflatable raft could not be launched. In doing so, the WESTPORT permitted successful rescue to be completed uninterrupted, thereby saving valuable time. Although all vessels and the WESTPORT were in communication with each other, none of the fishing vessels conveyed discontent to the WESTPORT. The crew members of the WESTPORT had participated in a number of joint SAR exercises involving designated SAR marine and air resources, and they were conversant with the established procedures and practices. On the other hand, with the exception of some fishing vessels from the Westport area that are designated Canadian Marine Rescue Auxiliary (CMRA), it is not common practice for local fishermen to participate in joint exercises aimed at safeguarding their individual or collective interests. Further, the local residents had witnessed joint exercises by the WESTPORT and a DND fixed- wing aircraft wherein magnesium flares had been dropped by the aircraft to illuminate the search area; therefore, they were under the mistaken impression that the WESTPORT was also capable of deploying them. 2.6 Obligations of Fishing Vessel Operators and Search and Rescue The positioning of a helicopter during the opening of the lobster season is intended to reduce transit time and provide quick response to emergency situations. However, in the interest of safety, the fishermen should ensure that adequate precautions are taken, consistent with the limitations of SAR response and transit times, and that their vessels are operated safely. 2.7 Inaccessibility of Life-saving Equipment in an Emergency Because of the limited space on small fishing vessels such as the STUMP JUMPER, lifejackets stowed in the accommodation and wheel-house often become inaccessible during an emergency. As thermal protection is critical for survival in the cold waters off the Canadian coast and as worksuits are designed to provide thermal and flotation capabilities, this occurrence once again highlights the need to carry and use worksuits. It is acknowledged that, under certain conditions, the worksuits may be warm to wear; however, in deciding whether to wear the worksuits or not, one must assess the risk factor. 3.0 Conclusions 3.1 Findings The operator made a navigational error while making an approach to the harbour. While entering the harbour, the operator received a message respecting change in port of destination. The operator's performance was probably impaired by the cumulative effects of his diabetic condition and work-induced fatigue. The operator had the hands-on control of the vessel and other crew members were not effectively deployed during the vessel's entry into the harbour. The use of a very high frequency radiotelephone (VHF R/T) frequency other than that requested by Coast Guard Radio Station (CGRS) Yarmouth precluded effective direct monitoring of the Search and Rescue (SAR) operation. A helicopter could not be dispatched until the CCGS WESTPORT arrived on scene because of a lack of information on the STUMP JUMPER. The response to the distress by the WESTPORT and the helicopter was prompt and well within the established response times. By the time the WESTPORT arrived on scene, rescue attempts by the fishing vessels were under way, and the WESTPORT played a supervisory but passive role in the rescue. The actions by the fishing vessels show their lack of appreciation of the requirements of a combined SAR effort. There is no requirement for fishermen to meet health standards nor is there a requirement concerning hours of work; following the grounding, the operator was incapacitated. The operator lost his life because he did not wear any form of flotation device, was unable to swim, was in poor health and became incapacitated. The flooding of the cuddy and the loss of power precluded the crew from gaining access to the lifejackets. Difficulties were experienced in deploying the vessel's inflatable liferaft and lifebuoy due to the violent motion of the vessel. 3.2 Causes The STUMP JUMPER grounded due to a navigational error while making an approach to the harbour, in part because the operator's performance was impaired by his poor health and work- induced fatigue. The fact that the operator, who could not swim, was not wearing any form of flotation device contributed to his loss. 4.0 Safety Action 4.1 Action Taken 4.1.1 Coast Guard Review Following the occurrence, the Canadian Coast Guard (CCG) reported conducting a review of the circumstances of the occurrence and its Search and Rescue (SAR) operation. The review concluded that the SAR operation was conducted properly; however, as a result of the review, the CCG will acquire searchlights for its rescue lifeboat fleet. 4.1.2 Skills, Training and Certification In its report on a 1993 collision between two fishing vessels (TSB Report No. M92M4031), the Board expressed concern that unqualified crew members with inadequate knowledge and skills in conducting navigational procedures were, at least in part, contributory in about 45 to 50 per cent of all collisions, groundings and strikings involving fishing vessels in Canada. Therefore, the Board recommended that: The Department of Transport ensure that any person required to have the conduct of a commercial fishing vessel possess the basic skills for safe navigation. Subsequently, the CCG prepared discussion papers following regional and national Canadian Marine Advisory Council (CMAC) meetings held at the end of 1994 and in early 1995, respectively. The discussion papers propose new certification schemes and describe CCG's intentions regarding regulatory changes to fishing vessel certificates and crew competency. The topic was further discussed at the CMAC national meeting held in Ottawa in October 1995. 4.1.3 Hours of Rest The Board also has expressed concern previously about the number of Canadian fishing vessels involved in marine occurrences in which issues related to crew fatigue were recorded. The current regulations affecting hours of rest (the Safe Manning Regulations) do not apply to personnel employed on Canadian fishing vessels. However, the Board understands that Transport Canada completed a study on the Review and Revision of the Safe Manning Regulations in January 1995. The study which focused on fatigue will form the basis for changes to the present Safe Manning Regulations, including provisions for minimum hours of rest for persons employed on fishing vessels.